PLEASE FILL OUT AND BRING WITH YOU

ADDRESS: ____________________________________________________________________________ Street City State Zip

EMERGENCY CONTACT : _______________________PHONE:________________________ RELATIONSHIP: _______________________________________ REFERRED BY: ____________________________________________________________________________ SKIN CARE GOAL?: ____________________________________________________________________________ PERSONAL HISTORY: Within the last year, have you been under the care of a dermatologist? YES ____ NO ____Within the last nine months, have you undergone any surgery? YES ____ NO ____Have you had any of these health problems in the past or present? YES ____ NO _______HIV/AIDS ___Diabetes ___Epilepsy ___Hormone Imbalance ___Thyroid Condition ___ Immune Disorder ___Blood Disorder ___Systemic Disease ___Hepatitis B or C ___Skin Diseases ___ CancerOther: __________________________________ List any medications, supplements, vitamins, etc., that you take regularly: ____________________________________________________________________________ Do you smoke? YES ____ NO _____

Do you have any special skin problems pertaining to your face? YES ____ NO _____If yes, please list: ____________________________________________________________________________ Do you wear contact lenses? YES ____ NO _____What skin care products are you currently using? _______________________________________________________ Have you had chemical peels, laser procedures or microdermabrasion? YES ____ NO _____Do you use Retin A, Renova, Accutane or Adapalene? YES ____ NO _____Most recent date: _______________ Do you use any acne medicine (prescription or OTC)? YES ____ NO _____Most recent date: _______________ Are you currently using any products with the following ingredients? ___Vitamin A Derivatives ____Glycolic Acid ___Exfoliating Scrubs ___ Lactic Acid __Hydroxy Acid Do you burn easily in moderate sunlight? YES ____ NO _____Do you blush easily when nervous? YES ____ NO _____What is your pain threshold? ___Low ___Medium ___High Have you ever had a reaction to any of the following?: ___Soap ___ Cosmetics ___Medicine ___Food___Iodine ___Pollen ___Latex ___Pigment ___ Sunscreen___Hydroxy Acids ___Fragrance ___Animals OTHER: ________________________________________ Are you susceptible to cold sores or fever blisters? YES ____ NO _____Are you susceptible to scarring (keloids)? YES ____ NO _____Do you have any known allergies to medications or any other substance? If so, list: ___________________________________________________________________

I HAVE ANSWERED THE ABOVE QUESTIONS ACCURATELY TO THE BEST OF MY KNOWLEDGE.